Doctors Medication Order Template for Campers
Camper Information
Camper Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Weight (kg)
Height (cm)
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
Parent/Guardian 1 Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Father
Mother
Relative
Legal Guardian
Parent/Guardian 2 Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Father
Mother
Relative
Legal Guardian
Current Data and Medical History
Kindly fill up the form below
Yes/No
Description/Remarks
Does the camper have any known allergies? If yes, then please specify in the Description field.
Yes
No
Is he/she currently taking any medications? If yes, then please list the medications and the reasons why the camper are taking them.
Yes
No
What is the current medical condition of the camper? Does he have any communicable disease, cardiovascular problems, diabetes, asthma, etc.?
Yes
No
Was the camper ever been hospitalized? If yes, please indicate why and when.
Yes
No
Did the camper undergo any previous surgery? If yes, please indicate the procedure name, reason, and the date.
Yes
No
Learning disabilities
Yes
No
Emotional or behavioral problems
Yes
No
Is the immunization up to date?
Yes
No
Medication Order
Medication Name
Schedule
Dosage
Route
Reason/Purpose
1
2
3
4
5
6
7
8
9
10
Physician Name
First Name
Last Name
Physician Phone Number
-
Area Code
Phone Number
Physician Signature
Clear
Date Signed
-
Month
-
Day
Year
Date
Note: All doctor's prescription order should be given to the health care team.
Select the following over the counter medications that can be given t the camper as nedded
Acetaminophen
Antacids
Anti-Histamine
Ibuprofen
Who will administer the medications?
Camper (Self-administer)
Health Care Staff
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform